2023

Concerns summary Prison and healthcare record systems failed to flag critical "trigger dates" for vulnerable prisoners. Staffing shortages prevented thorough record review, and system limitations meant crucial information was frequently overlooked.

Concerns summary Insufficient medical cover over a bank holiday period meant no doctor assessed the patient for four days, highlighting a lack of attention to subtle care needs beyond emergencies.

Concerns summary Mental health services lack adequate training and clarity for supporting transgender individuals, coupled with significant delays and insufficient mental healthcare provision for those awaiting gender-affirming treatment.

Concerns summary A critical lack of compulsory mountain flying training and guidance for UK PPL(A) license holders means pilots undertake hazardous flights without adequate knowledge of specific risks and tactics.

Concerns summary Vulnerable adults under secondary mental health services who are at risk of prescription drug overdose and mental health crisis receive insufficient or no support.

Concerns summary Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the risk of undetected incidents in busy stations.

Concerns summary There are no guidelines for the delegation of nursing duties to family members, leading to unacceptable care levels and a lack of clear supervision or intervention by the nursing team.

Concerns summary The prolonged prescription and use of opiate medication pose significant dangers to patients.

Concerns summary National shortages of specialist scanning facilities and delays in the two-week cancer pathway lead to delayed diagnoses and treatments, resulting in poorer patient outcomes and advanced disease.

Concerns summary A deteriorating patient with a high NEWS score was not reviewed by specialist consultants. Risks of the ascitic tap procedure were unquantified and potential for death was not disclosed during consent.

Concerns summary Significant ambulance response delays resulted from insufficient resourcing and extended patient offloading times at hospitals, preventing timely emergency call responses.

Concerns summary A lack of clear national or standardized trust policy on escalating issues when an external ventricular drain stops draining but oscillates poses a significant patient safety risk.

Concerns summary The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and insufficient staff training and risk assessment for a resident with evolving dementia.

Concerns summary A lack of clarity exists between Acute and Mental Health Trusts regarding the Mental Health Liaison Team's role and appropriate referral pathways to specialist eating disorder services.

Concerns summary The Venous Thromboembolism Prevention Policy lacked provisions for risk assessment in patients attending hospital but not admitted, leaving a critical gap in VTE prevention.

Concerns summary A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients don't collect essential prescriptions, poses a significant risk.

Concerns summary Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of clear responsibility for ensuring their transfer, risking incomplete medical history.

Concerns summary The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal opiate overdoses, and the implementation of proposed changes is unclear.

Concerns summary Derbyshire Constabulary showed serious failings in investigating stalking, with inadequate officer training and understanding, alongside a lack of comprehensive and ongoing risk assessments.

Concerns summary An unspecified risk of death exists in similar circumstances; public awareness, especially for child carers, is crucial to reduce these risks.

Concerns summary The Shared Care Record system lacks automated flags for long-term steroid monitoring and a field for recording clinical indications, posing risks for unsafe prescribing.

Concerns summary Care staff with insufficient English proficiency pose a risk to vulnerable patients by hindering effective communication with emergency services, potentially delaying urgent medical attention.

Concerns summary The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved outcomes and survival rates.

Concerns summary Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and inadequate risk assessment formulation in patient care.

Concerns summary Elderly patients with complex needs on surgical wards receive inadequate holistic care due to a national shortage of geriatric specialists. Ambulance staff demonstrated inconsistent fall risk assessment and insufficient training.